The potential effect of a vibrotactile glove rehabilitation system on motor recovery in chronic post-stroke hemiparesis

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1 Technology and Health Care 25 (2017) DOI /THC IOS Press Technical Note The potential effect of a vibrotactile glove rehabilitation system on motor recovery in chronic post-stroke hemiparesis Hsiao-Ching Wu a, Yi-Ching Liao a, Ya-Hsing Cheng a, Pei-Cheng Shih b, Chia-Min Tsai c and Chi-Ying Lin c, a Department of Physical Medicine and Rehabilitation, Division of Physical Therapy, Mackay Memorial Hospital, Taipei, Taiwan b Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany c Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei, Taiwan Received 9 July 2017 Accepted 3 August 2017 Abstract. BACKGROUND: Poor fine motor skills are common among chronic stroke patients. Conventional rehabilitation programs only emphasize intensive and repeated exercises that do not motivate patients to continue rehabilitation. Using a vibrotactile glove rehabilitation system with a human-computer interaction interface can therefore resolve this issue. OBJECTIVE: The objective of this study was to examine the potential benefits of this vibrotactile glove rehabilitation system for chronic stroke patients who have already reached the recovery plateau. METHODS: Two interesting computer games were designed to coordinate with the vibrotactile gloves in patient training. The training sessions lasted for about 30 minutes twice a week for five consecutive weeks. We compared finger ROM, grip strength, pinch strength, NHPT, and MHQ results before and after the intervention and surveyed subject satisfaction afterwards. RESULTS: The subjects showed slight improvements in muscle strength and hand after five weeks. The patients reported progress, but the differences did not reach statistical significance. In the satisfaction questionnaire, the subjects gave positive ratings. CONCLUSIONS: This vibrotactile glove rehabilitation system has the potential to help chronic stroke patients who have reached their recovery plateau to make progress and is clinically quite effective in increasing their motivation. Keywords: Motor recovery, hemiparesis, vibrotactivel glove Corresponding author: Chi-Ying Lin, Department of Mechanical Engineering, National Taiwan University of Science and Technology, Taipei 106, Taiwan. chiying@mail.ntust.edu.tw /17/$35.00 c 2017 IOS Press and the authors. All rights reserved

2 1184 H.-C. Wu et al. / The potential effect of a vibrotactile glove rehabilitation system on motor recovery 1. Introduction Neuro-Developmental Treatment/Bobath s Approach [1] is a conventional rehabilitation method in clinical practice to improve the upper limb functions of stroke patients. However, it is generally ineffective. New rehabilitation methods in recent years include constraint-induced movement therapy (CIMT) and auxiliary treatments combining virtual reality with robotics and computer gaming [2]. CIMT is an intensive rehabilitation method that prompts stroke patients to use their affected upper limb. Literature shows that CIMT produces significant clinical improvements in upper limb functionality and level of activity [3]. However, the training content of CIMT is very stringent, so some patients are resistant to it. Chronic patients reach a recovery plateau after more than six months post-stroke, and limited progress can cause patients to become less motivated to continue rehabilitation. Robot-assisted rehabilitation is a means of giving stroke patients intensive training for their affected fingers while enhancing their willingness to receive rehabilitation [4,5]. Recent studies have found that using force feedback rehabilitation systems has a positive impact on patients with neural damage [6,7]. For instance, authors in [8] have also proposed a vibrotactile glove rehabilitation system that uses vibration stimuli in coordination with human-computer interaction game interfaces to motivate users in rehabilitation and repeatedly trains the accuracy and speed of individual finger movements to improve hand dexterity. The objective of this study was to examine the potential benefits of this vibrotactile glove rehabilitation system for chronic stroke patients who have already reached the recovery plateau. 2. Materials and methods 2.1. System setup The vibrotactile glove system is a finger training system in which users interact with the computer. The glove is designed with light fabric for greater wearability. Vibration motors are installed at the proximal interphalangeal (PIP) joint and metacarpophalangeal (MCP) joint of each finger on the dorsal side. Patients interact with the computer via a magnetic plate on which the places where patients should lay their fingers can be adjusted according to the size of their hand. The magnetic plate is equipped with a force sensor that gauges how hard the fingers press [8] Intervention Subjects The subjects of this study were chronic stroke patients that had been receiving rehabilitation therapy at the Taipei Mackay Memorial Hospital for several months. The inclusion criteria included (1) age: years, (2) chronic stroke ( 6 months post-stroke), and (3) Brunnstorm recovery stage 4 for upper extremity. The exclusion criteria included (1) cognition deficits, (2) biomechanical limitations (e.g., contracture of the muscles in their wrist and hand), (3) individuals whose visual or hearing impairment does not allow possibility of interaction with the system, (4) severe hemispatial neglect, (5) severe cardiopulmonary disease, and (6) impaired vibration sensation of affected hand. A total of nine subjects fitting the criteria above participated in this study (Table 1). Ethical approval for this clinical study was granted by the Institutional Review Board of the Mackay Memorial Hospital. All eligible candidates who agreed to take part in the study were required to provide informed consent.

3 H.-C. Wu et al. / The potential effect of a vibrotactile glove rehabilitation system on motor recovery 1185 Table 1 Subject characteristics and clinical data Subject n = 9 Gender (n) Male 7 Female 2 Age (yr) Mean ± SD 62.9 ± 6 Stroke type (n) Infarction 7 Hemorrhage 2 Time poststroke (months) Mean ± SD 35.5 ± 10 Dominant hand affected (n) 6 Modified ashworth scale (wrist flexor) (n) Brunnstrom stage U/E (P/D) IV/IV 2 V/V 7 Sensation: light touch (hand) (n) Intact 9 Sensation: proprioception (wrist, finger) (n) Intact Protocol All of the subjects in this study were chronic stroke patients that had been receiving physical therapy and occupational therapy for several months at the hospital. The contents of the therapy included taskoriented training and upper limb strengthening sessions about half an hour long twice a week. Aside from conventional rehabilitation exercises, they were also recruited to participate in training with the vibrotactile glove system (human-computer interaction games for about 30 minutes twice a week for five consecutive weeks). Each game session comprised six rounds of either a gopher hitting game or a note hitting game [8] Outcome measurement The motor performance of the subjects were evaluated before and after the five-week intervention by an experienced physical therapist. Outcome measurement included range of finger motion, grip/pinch strength, the Nine-Hole Peg Test (NHPT) [9], and the Michigan Hand Outcomes Questionnaire (MHQ) [10]. At the end, the patients were also asked to fill out a satisfaction questionnaire. We designed a satisfaction survey containing the five satisfaction items: Interest, Comfort, Duration, Effectiveness, and Continuing participation. The possible responses for these items included not satisfied at all, not very satisfied, more or less satisfied, quite satisfied, and very satisfied. Paired-t tests were used to determine whether significant differences existed between pre-intervention and post-intervention conditions. 3. Results and discussion No significant differences were found in all physical measurements among two time points (P > 0.05). Table 2 presents the details of the outcome measurement results, where finger ROM: P = 0.817; grip strength: P = 0.6; tip pinch: P = 0.624; lateral pinch: P = 0.864; NHPT: P = The MHQ scores showed no significant differences, and the scores of each of the six domains were shown in Fig. 1. The P values of the statistics were P = 0.86/0.074/0.81/0.2/0.903/ However, consistent reports of high satisfaction score were found in all patients. According to the survey, the patients expressed a high level of satisfaction after using the system. Eight out of the nine patients felt that glove system was interesting as a rehabilitation; seven felt that using the

4 1186 H.-C. Wu et al. / The potential effect of a vibrotactile glove rehabilitation system on motor recovery Table 2 Difference between finger ROM, grip strength, pinch strength, and NHPT (before and after intervention) Before After P-value Finger ROM (degree) Grip strength (kg) ± ± Tip pinch (kg) 5.56 ± ± Lateral pinch (kg) 5.67 ± ± NHPT (s) ± ± Fig. 1. MHQ score. system was comfortable; seven indicated that the duration of training was appropriate; eight felt that the glove system was effective in improving hand function, and eight were willing to use the glove system as part of their rehabilitation program in the future. The vibrotactile glove rehabilitation system in this study did not lead to significant differences, which is likely due to the small sample size and measurement errors. There was no control group, and the training period in this study was only five weeks, which is relatively short for chronic stroke patients who have already been receiving treatment for more than three years. Nevertheless, the subjects expressed high levels of satisfaction with various aspects of the system and were very willing to continue using it for rehabilitation. Future studies can lengthen the treatment period and add a control group to analyze the differences between pre-intervention and post-intervention conditions. Further investigation can also be conducted on the clinical effects of this training tool for home use. Acknowledgments The authors would like to thank Ministry of Science and Technology, Taiwan, for providing financial support of this research under grant number MOST E They are also grateful to the clinic help from Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei, Taiwan.

5 Conflict of interest None to report. H.-C. Wu et al. / The potential effect of a vibrotactile glove rehabilitation system on motor recovery 1187 References [1] Bobath B. Adult hemiplegia: evaluation and treatment. London, England: Heinemann; [2] Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet May; 377(9778): [3] Taub E, Crago JE, Uswatte G. Constraint-induced movement therapy: a new approach to treatment in physical rehabilitation. Rehabil Psychol. 1998; 43(2): [4] Pignolo L. Robotics in neuro-rehabilitation. Journal of Rehabilitation Medicine Nov; 41(12): [5] Sivan M, O Connor RJ, Makower S, Levesley M, Bhakta B. Systematic review of outcome measures used in the evaluation of robot-assisted upper limb exercise in stroke. Journal of Rehabilitation Medicine Feb; 43(3): [6] Choi KS, Lo KH. A hand rehabilitation system with force feedback for children with cerebral palsy: two case studies. Disability and Rehabilitation. 2011; 33(17-18): [7] Villeneuve M, Lamontagne A. playing piano can improve upper extremity function after stroke: case studies. Stroke Research and Treatment. 2013; 2013, Article ID , 5 pages. [8] Lin CY, Tsai CM, Shih PC, Wu HC. Development of a novel haptic glove for improving finger dexterity in poststroke rehabilitation. Technology and Health Care. 2016; 24(S1): S97-S103. [9] Oxford Grice K, Vogel KA, Le V, Mitchell A, Muniz S, Vollmer MA. Adult norms for a commercially available nine hole peg test for finger dexterity. Am J Occup Ther Sep-Oct; 57(5): [10] Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of the Michigan hand outcomes questionnaire. J Hand Surg Am Jul; 23(4):